What suicide prevention policy should be adopted in a country that allows euthanasia for depression?

As in the cases of Shanti De Corte (a survivor of the terrorist attacks at Zaventem airport who underwent euthanasia at the age of 23), Tine Nys (euthanised at the age of 38) and others suffering from depression or other mental illnesses, the media coverage of Siska's euthanasia has reignited the public debate on the shortcomings of the mental health care system in Belgium, but also on the appropriateness of euthanasia as a response to such situations of suffering. 

It should be noted that, since its adoption in 2002, Belgian law on euthanasia has never made access to euthanasia conditional on the patient being terminally ill or at the end of life. The ‘unbearable and incurable’ nature of the suffering and the existence of an “incurable” condition are the two central criteria in the Belgian framework. Added to this is the condition that both the doctor and the patient must be convinced that ‘there is no other reasonable solution in their situation’. 

This has led to euthanasia being increasingly considered as a ‘medical’ response for certain patients suffering from chronic depression, personality disorders or even autism (as in the case of Tine Nys). 

Lack of consensus on the incurable nature of depression 

However, we know that there is no consensus, on a scientific level, as to whether certain types of depression or other chronic mental illnesses can be considered incurable, as required by the law on euthanasia (see EIB News 22/01/2020). Many Belgian psychiatrists and psychologists have therefore been questioning the practice of euthanasia based solely on mental disorders for several years (see, for example, the opinion piece published in January 2018 in De Morgen). Many psychiatric patients whose requests for euthanasia had already been accepted (and whose situation was therefore considered incurable) ultimately changed their minds, for example after finding love or reconciling with their families. One example is the case of Emily, who was 24 years old in 2015 and was the subject of a documentary video by The Economist magazine about her request for euthanasia due to depression (‘24 and ready to die’): despite a favourable opinion from doctors, the young woman renounced euthanasia at the last minute. 

Euthanasia presented as an alternative to suicide 

Formally, however, there has never been any serious discussion of revising the legal framework for euthanasia for mental disorders in Belgium. In several of its official reports, the Federal Commission for the Control and Evaluation of Euthanasia (FCCEE) indicated that "among young patients, [...] failed suicide attempts made those concerned aware that there was also another, more dignified way to end their lives [editor's note: namely euthanasia]." (see, for example, the 2018-2019 report, p. 41). 

In other words, the Commission officially responsible for monitoring the legality of euthanasia cases reported by doctors and assessing the application of Belgian law considers euthanasia to be an alternative to suicide attempts among young people. 

Euthanasia and suicide prevention: how consistent are they? 

In these circumstances, how can we conceive of the pursuit of suicide prevention policies by a state that, at the same time, allows and organises the euthanasia of certain people suffering from mental disorders? If a psychiatric patient's request for euthanasia is deemed to be ‘voluntary, well-considered and repeated’ and free from "external pressure " (Art. 3, §1 of the law), a suicide attempt can in reality be just as voluntary, to such an extent that there is no formal distinction between the two practices, except in the case of euthanasia, where doctors intervene to validate the request for death and carry it out. 

Mental health crisis: the calming effect of euthanasia as a last resort? 

At the same time, data on mental and social health in Belgium show that mental disorders are a major public health problem compared to other EU countries, particularly in terms of suicide and attempted suicide rates. Among those particularly at risk of developing such disorders are adolescents and young adults, notably since the COVID-19 health crisis, but also the elderly. 

In this context, some believe that “offering” a psychiatric patient the option of euthanasia as a last resort would allow them to live with their illness in a more peaceful manner, knowing that this option of “clean” and “more dignified” suicide " (to use the terms of the FCCEE) would be available to them, thus preventing them from attempting suicide if necessary. 

Euthanasia and suicide: not so far apart? 

However, the studies available on the subject do not seem to demonstrate a positive impact of making euthanasia available to psychiatric patients on the overall suicide rate. On the contrary, according to a review of the literature carried out by the Anscombe Bioethics Centre, it appears that the possibility of euthanasia leads some patients who would not have considered suicide in the absence of such a possibility to request euthanasia. 

While euthanasia is generally presented in public debate as unrelated to the issue of suicide, certain factual links between the two issues are now becoming apparent. Although the law still requires the presence of an incurable condition as a prerequisite for euthanasia, the subjective interpretation of the conditions of suffering and illness associated with a request for euthanasia makes some requests for euthanasia difficult to distinguish from a desire for suicide. This is evidenced by the increasingly frequent mention in recent years of the telephone number of the suicide prevention centre's helpline in Belgian press articles on euthanasia. 

What freedom of choice is there in the face of inadequate care? 

More fundamentally, the euthanasia of Siska De Ruysscher highlights the failures of the Belgian mental health and psychiatric care system, both in terms of its lack of resources and the inadequacy of its prevention and treatment methods. As Siska herself testified through the media coverage of her recourse to euthanasia, waiting times, lack of follow-up and isolation made her ‘the product of a failing system’. 

In the absence of truly accessible and effective psychiatric care, euthanasia for mental disorders no longer appears to be the result of individual autonomy and freedom, but rather the extreme consequence of the failure of society and the authorities to effectively support and relieve these vulnerable individuals. 

In addition to improving the care of these patients, the challenge now is to include the prevention of euthanasia for mental disorders in suicide prevention policies and, as many doctors and scientists are calling for, to genuinely re-examine the legal and medical framework for euthanasia in the case of psychiatric patients.